Under the direction of the CMO, this position is responsible for medical management and key leadership functions that support Medicaid strategic initiatives. This position helps direct medical operations for the product and supports the development of reliable, innovative clinical processes, analytics, and product solutions that produce excellent results for members and the plan. In this role, the Medical Director will work collaboratively with product leaders to oversee operational and financial goals and drive improvements that address complex trends in quality, care management, and provider relations. The position will serve as a role model in upholding the values, business objectives, and service expectations of the UPMC Insurance Division. The Medical Director will also supervise medical staff assigned to these products and work closely with Product and all other areas of clinical and operational leadership.
Thought Leadership- Stay current on innovative care delivery models and trends; gather, adapt, and apply market intelligence to inform the design of Health Plan products, programs, and business opportunities.
- Leverage technology, as appropriate, optimize product and program performance, member engagement, and member benefit.
Strategy Development - Collaboratively support and develop strategic, tactical, and financial plans to optimize Medicaid product and quality performance and member experience; support continued product growth and development while ensuring beneficiaries' needs are well served, with a strong emphasis on quality and value.
- In collaboration with other leaders, develop and lead initiatives for the Medicaid plan.
- Develop and direct clinical strategies to improve quality and financial results for the Medicaid product.
- Align Medicaid products with new and emerging regulatory requirements and policies. Represent the Medicaid product and Health Plan in public settings, as needed.
- Establish, create and have institutional working knowledge on Value Based Programs, Pay for Performance designs and all other specific product line initiatives.
Operations Management - Partner with other Medicaid leaders to establish operational and financial goals for products and programs; actively monitor trends and manage performance against those goals.
- Define and drive the implementation of analytics and information systems to manage and report on Medicaid products and chronic care programs.
- Develop and maintain effective internal relationships with key stakeholders, including network providers, community organizations, DHS, and other government organizations.
- The Medical Director will be actively involved in all major clinical program components and directly participate in oversight of the Enhanced Member Support Unit (EMSU), Quality Management (QM) Department, and Utilization Management (UM) Department, including determinations of service or benefit medical necessity and appropriateness and continued inpatient stays beyond approved days, according to established criteria.
- The Medical Director and his/her staff or consultant physicians will devote sufficient time to collaborating with departments to support clinical, operational, and strategic goals and provide timely medical decisions, including after-hours consultation, as needed.
- Collaborate on the review of annual budget discussions with DHS.
- This position will be directly accountable to, and act as liaison to, the Chief Medical Officer for DHS and will have the following responsibilities:
- Serves as liaison and is accountable to the governing body and Quality Management Committee for all QM, UM and QI activities and initiatives
- Is available to the PH-MCO's medical staff for consultation on referrals, denials, Complaints and problems;
- Is directly involved in the PH-MCO's recruiting and credentialing activities;
- Is familiar with local standards of medical practice and nationally accepted standards of practice;
- Has knowledge of due process procedures for resolving issues between participating Providers and the PH-MCO administration, including those related to medical decision making and utilization review;
- Is available to review, advise and take action on questionable hospital admissions, Medically Necessary days and all other medical care and medical cost issues;
- Is directly involved in the PH-MCO's process for prior authorizing or denying services and is available to interact with Providers on denied authorizations;
- Has knowledge of current peer review standards and techniques;
- Has knowledge of risk management standards;
- Is directly accountable for all Quality Management, Utilization Management and Quality Improvement activities and
- Oversees and is accountable for:
- Referrals to the Department and appropriate agencies for cases involving quality of care that have adverse effects or outcomes; and
- The processes for potential Fraud and Abuse investigation, review, sanctioning and referral to the appropriate oversight agencies.
Organizational Leadership - Define and manage resources, including Medical Directors and other clinical staff, to achieve strategic and operational goals for Medicaid initiatives. Develop and mentor physicians and other managers as effective leaders, promoting high engagement. Serve as an executive role model for UPMC's core values and mission.
- Work with medical, nursing, and operations leaders to advance UPMC's capabilities in chronic care program development.
- Perform in accordance with system-wide competencies and behaviors.
- Perform other duties as assigned.
Responsibilities: - Assist with the development of a clinical organization which prioritizes the retrieval and intuitive interpretation and evaluation of statistics and medical trends in order to establish aggressive preventative health targets and objectives.
- Serve on physician committees and work with each Health Management program to monitor, assess and ensure the program's clinical success. Establish best practices for care programs including Diabetes, Asthma, Congestive Heart Failure, End-Stage Renal Disease and Maternity Programs.
- Create progressive physician group and provider education programs; direct concurrent education and communication related to credentialing, UM, and QI. The Senior Medical Director will be responsible for the Technical Assessment Committee (TAC).Establish and implement superior performance standards while maintaining compliance with applicable statutes, rules and regulations, the standards of accrediting bodies and corporate policies and compliance program standards.
- Collaborate with VP, Medical Affairs and to engage all functional areas of the Health Plan from a clinical perspective to develop innovative programs as well as products lines; serving as the primary clinical liaison with Network Services, Strategic and Advisory Services, Finance and Underwriting, Operations, Information Systems, Pharmacy, and Product Development.
- Serve as an integral part in the design and implementation of medical management initiatives such as disease management to improve quality and cost effectiveness of care delivered to Commercial, Medicare and Medicaid members.
- Swiftly respond to challenges and/or opportunities as they arise. Develop and implement innovative programs to act on historical data, identifying new trends, retooling existing approaches, and analyzing the competition.
- Collaborate with physicians to develop clinical programming by accessing and mining clinical data, devising methods to manage populations. Partner with physicians to improve reimbursement model and performance based physician incentive programs.
- Collaborate with Vice President, Medical Affairs, and Health Plan senior leadership in the development of short-term, mid-term, and long-range strategic planning for the Health Plan. Partner with physician leaders, and hospital and business executives to exceed clinical, operating, financial, quality, and market share objectives. Deliver executive level presentations for UPMC senior management and other designated groups.
- Lead the Utilization Management organization, Pod functions, as well as Quality of Care; leading management of 2nd level grievances, guiding and managing the most complex cases, appeals, quality regulatory requirements, credentialing, trouble-shooting and special investigations.
- As an integral member of UPMC Health Plan's leadership team, serve as a 'role model' and 'health advocate' within the Western Pennsylvania community, including active participation with UPMC sponsored activities, public events and community outreach programs.
- Provide clinical leadership and support for Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of HEDIS reporting, as well as meeting or exceeding all regulatory requirements. Serve as Clinical Leader for the UPMC for Life Medicare program.
- Identify opportunities to further integrate information systems and departmental interface capabilities, and from a clinical perspective, assist in affecting the 'phase-in' of newly acquired OAO interactive software.
- Directly participate in the oversight of the QM Department and the UM Department.
- As a clinical 'thought leader' and UPMC Health Plan physician liaison, participate in the creation of opportunities to consult, interact and elicit feedback with the physician community, then act upon this valuable information, raising proactive clinical intervention to unprecedented levels.
- Nurture personal and professional growth/development by attending seminars, workshops, and establishing professional affiliations to keep abreast of latest trends in field of expertise.
- Ensure continuous improvement strategies are established and implemented for Health Management outcomes and processes, encouraging a culture which initiates intensive and persistent case management for members.
- Influence medical cost trend in partnership with network services and medical management team, including development of trend-specific initiatives, provider fee schedule review, and identification of medical management best practices. Create opportunities to integrate pharmaceutical and medical strategy with innovative solutions.
- Interface with UPMC Health System cross-functional and shared resources to further the 'cause' to create a seamless healthcare patient-flow management process and insurance model.
- Motivate and mentor UPMC Health Plan's clinical Medical Affairs staff by 'setting the pace' and fostering 'excellence by example'. Assess the overall team, including ongoing recruitment and hiring of talent. Ensure that the organization has the 'right people' in the 'right positions' and that the organization's structure is designed to maximize results.
- Collaborate with the VP, Medical Affairs and Chief Medical Officer to develop unique partnerships and differentiated relationships with current and prospective employer groups, consultants and brokers, in order to understand and meet their health and welfare needs.
- Passionately manage UPMC Health Plan's clinical Medical Affairs organization for Commercial, Medicare and Medicaid lines of business, to include; leading, educating and mentoring Medical Directors, managing all clinical aspects of Medical Management, Quality, Health Management, Utilization Management, Disease Management, Strategic Planning and Policy.
Qualifications: - Qualifications
- Minimum ten years clinical experience preferred
- Doctor of Medicine or Doctor of Osteopathy from an accredited school. Unrestricted License in Pennsylvania.
- Post residency clinical experience.
- Clinical experience in geriatrics or other disabled populations preferred.
- At least ten years of management experience preferred. Experience in managed care setting preferred.
- Ability to implement medical policies, and to enforce those policies through appropriate action.
- Ability to maintain effective professional liaison with all levels of executive and medical staff, including professional and institutional providers of care.
- Ability to implement programs of quality care analysis, peer review, and professional education.
- Board Certification in ABMS American Board or Medical Specialists preferred
The Senior Medical Director will possess extensive experience in clinically leading Medical Affairs within a progressive managed care organization, ideally having created and driven innovative clinical program initiatives as well as having initiated NCQA accreditation and certification. Experience within a health plan that has truly developed a relationship with the physician and patient community; genuinely collaborative in nature, value-added versus commodity-driven, cross-functionally efficient and consumer-driven. Will possess a passion and commitment to help change the way healthcare is delivered, a track record of developing leading-edge Health Plan clinical strategies while motivating an organization to achieve 'stretch goals' to drive innovation, and do 'what is right today, rather than tomorrow. Ability to lead, motivate and mentor superior Medical Directors in pursuit of progressive programming. Solicit support, evaluate, direct and hold one's self and employees accountable, while maintaining high morale and productivity during favorable and unfavorable conditions. Expert managed care clinical leadership skills, leveraging a broad knowledge base in managed care. Must possess a global understanding of the industry: legislative/regulatory developments, national product and delivery trends, maintenance of key industry relationships and tracking competitors. Highly developed interpersonal and communication skills, both written and verbal, and an executive demeanor which
